A rare case of pancreatic tail tuberculosis and literature review: a case report

Abstract

Introduction and importance:

Pancreatic lesions can present with vague, nonspecific symptoms and may mimic malignancy or infections such as pancreatic tuberculosis (TB), especially on imaging. Pancreatic tail tuberculosis is an exceedingly rare phenomenon and is rarely reported. While MRI with contrast and diffusion-weighted imaging helps characterize these lesions, histopathology remains essential for definitive diagnosis.

Case presentation:

A 62-year-old female presented with vague, intermittent colicky pain around the umbilical area, accompanied by notable weight loss and a decrease in appetite. He also experienced a dry, intermittent cough lasting the same duration. There were no signs of fever, night sweats, jaundice, a history of tuberculosis, or contact with anyone who had a chronic cough. Physical examination revealed mild epigastric tenderness with no palpable masses. Laboratory investigations, including liver function tests and pancreatic enzymes, were within normal limits. An abdominal ultrasound and CT scan performed at the referring hospital both indicated a pancreatic mass. The institution, ultrasound-guided fine needle aspiration cytology (FNAC) of the pancreatic tail was conducted, which revealed findings consistent with tuberculosis. There were no other indications of malignancy. The patient was initiated on an anti-TB regimen and showed clinical improvement. She is currently on follow-up at the institution.

Clinical discussion:

Imaging findings raised suspicion for a malignant neoplasm such as pancreatic adenocarcinoma or neuroendocrine tumor. However, features like central necrosis and lymphadenopathy are also seen in pancreatic TB. Differentiation between malignancy and TB based solely on imaging is challenging, particularly in endemic regions. Histopathological analysis through biopsy is critical to confirm the diagnosis and avoid mismanagement, as TB is a treatable condition with medical therapy.

Conclusion:

This case highlights the importance of correlating clinical, radiologic, and pathological findings when evaluating pancreatic lesions. A tissue diagnosis is crucial for distinguishing between malignancy and uncommon infections such as pancreatic tail tuberculosis, which was performed in a patient. Following this diagnosis, the patient showed clinical improvement with anti-TB treatment during follow-up.

Introduction

Background: The most common organ affected by tuberculosis (TB), a contagious disease brought on by Mycobacterium tuberculosis, is the lung. Extrapulmonary TB (EPTB), which makes up a sizable portion of TB cases worldwide, is another way it might manifest. Low- and middle-income nations, which collectively bear 98% of the global burden, are where the majority of TB cases occur^[1]. Less than 5% of TB cases have pancreatic involvement, according to post-mortem investigations, making pancreatic TB (PTB) an extremely uncommon symptom of EPTB^[2]. The natural resistance of the pancreas to the disease, which is probably due to the proteolytic and antibacterial qualities of its enzymes that can destroy mycobacteria, is the reason why pancreatic TB is uncommon. Pancreatic TB is often missed or misdiagnosed due to its infrequent occurrence and vague clinical signs^[3].

HIGHLIGHTS

• Pancreatic tuberculosis is an extremely rare form of abdominal TB, with very few cases documented in the literature.

• Its clinical presentation often mimics pancreatic malignancy or other mass-like lesions, making diagnosis challenging and easily overlooked.

• Accurate diagnosis is crucial, as it helps distinguish pancreatic TB from neoplastic masses and avoids unnecessary surgical interventions.

• Histological confirmation is essential, and the diagnostic and management approach should involve a multidisciplinary team to ensure timely and appropriate care.

Rationale: Even less common, primary pancreatic tuberculosis (PPTB) affects only 0.46% of TB patients and is characterized by isolated pancreatic involvement without active disease elsewhere in the body^[4]. The head of the pancreas is affected in the majority of documented cases^[5], with tail involvement being extremely uncommon. Pancreatic TB was previously identified in autopsy series in 4.7% (1944) and around 2% (1966) of TB cases; however, in recent years, enhanced clinical awareness and better diagnostic imaging have led to greater detection^[6]. Due to overlapping radiological findings and similar clinical symptoms, including anorexia, weight loss, and abdominal pain, it is commonly misdiagnosed as cancer^[7]. This frequently leads to postponed diagnosis and even needless surgical procedures^[6]. Pancreatic tuberculosis must be considered in the differential diagnosis of pancreatic masses in regions where TB is endemic or in individuals who have pertinent risk factors like HIV or immunosuppression^[5].

Guidelines and Literature Review: Standard TB management protocols stress the significance of tissue diagnosis in suspected cases of EPTB, notwithstanding the lack of disease-specific criteria for PTB. Histopathological confirmation, which is crucial for diagnosis, requires the use of image-guided fine-needle aspiration cytology (FNAC) or biopsy. A surgical biopsy can be necessary if non-invasive techniques prove inconclusive. Standard anti-tubercular therapy (ATT) can efficiently treat pancreatic tuberculosis once it has been diagnosed, negating the need for major surgery. As far as we are aware, this is the first case report of pancreatic tail TB in sub-Saharan Africa to be identified by histology. In accordance with the revised 2025 SCARE rules, we provide this example^[8].

Case presentation

A 62-year-old female patient presented to the institution with a complaint of periumbilical pain, which she described as dull and intermittently colicky. The pain had been ongoing for the past 4 months and was associated with significant weight loss and a reduced appetite. The patient also mentioned experiencing an intermittent dry cough that has persisted for the same duration. There was no reported history of fever, night sweats, jaundice, diarrhea, vomiting, or changes in urine color. The patient is a housewife with no known exposure to individuals with chronic coughs or those diagnosed with tuberculosis. Additionally, she has no history of smoking, alcohol use, or any recognized chronic medical conditions. The physical examination indicated a chronically ill appearance, characterized by noticeable weight loss, prominent zygomatic bones, and a BMI of 17.3 kg/m². The abdominal examination revealed mild tenderness in the epigastric region upon palpation, while other physical findings were within normal. Based on these findings, she underwent further investigation, including laboratory tests and imaging studies. CBC showed WBC of 9.7k, platelet count 502, hemoglobin 12.7 mg/dl (Table 1). Abdominal ultrasound was done and revealed a hypoechoic pancreatic body/tail mass measuring 4.26 cm × 3 cm and suggested a pancreatic neoplasm (Fig. 1). An abdominopelvic CT scan was also done and showed a septated pancreatic body cystic mass measuring 4.4 cm × 4 cm × 3.2 cm with multiple mesenteric and retroperitoneal enlarged lymph nodes. Other tests, like urine analysis and blood film, were unremarkable.

Table 1.

Investigation summary

Investigation	Result			Unit	Reference Range
	Day 1	Day 7	2 month
CBC
WBC	9.7			103	3.9–10.1
Neutrophils	70.9			%	40.4–74.6
Hemoglobin	12.7			g/dl	12.7–17.1
Hematocrit	36.3			%	34.4–48.3
Platelet	502			× 109/l	100–300
Liver function test
Alkaline  Phosphatase	117			U/l	55–149
ALT (SGPT)	17			U/l	0–41
AST (SGOT	15			U/l	0–40
Bilirubin Direct	0.1			mg/dl	0.1–0.4
Bilirubin Total	0.3			mg/dl	0.3–1.2
Electrolytes
Sodium				mmol/l	135–145
Potassium				mmol/l	3.5–5.1
Chloride				mmol/l	98–107
Renal Function Test
Creatinine	0.6			mg/dl	0.7–1.2
Urea	19			mg/dl	16.5 − 48.5
Others
FBS	95			mg/dl	70–100
CA-19-9	<3			µ/ml	0–37
CEA	0.448			ng/ml	0–3
ESR	240			mm/hr	<22
PICT	NR

Figure 1.

Transabdominal ultrasound: there is a 4 × 3 cm measuring hypoechoic heterogeneous solid mass lesion with irregular margin in the body of the pancreas.

Based on the above findings, a diagnosis of pancreatic neoplasm with metastases was considered and referred to the institution for further histologic investigation. On examination, the patient was emaciated and chronically sick-looking. The conjunctiva was pink, and she was not icteric. There was no palpable lymph node, and abdominal examination did not reveal particular findings. Laboratory investigations, including CBC, liver function tests, serum electrolytes, and renal function tests, were normal. Tumor markers such as CEA, CA 19.9, and CA-125 were within normal range. Ultrasound-guided FNAC of the pancreatic tail was done, and showed a pancreatic tail lesion with well-formed granulomas and multinucleated giant cells along with degenerating cells in a necrotic background (Fig. 2A and B). There were no features of malignancy seen. Thus, the patient was diagnosed with pancreatic tail tuberculosis.

Figure 2.

(A). Mid power view (20x) shows Langhans (blue arrow) and foreign body (black arrow) type of giant cells along with sheets of neutrophils. (B). High power view (40x) nodular aggregates of epithelioid cells forming a granuloma (black arrow) along with central dusty amorphous necrosis (blue arrow).

The patient was subsequently given an anti-TB medication combination regimen consisting of rifampicin, isoniazid, Pyrazinamide, and ethambutol (RHZE) at a dosage of four tablets daily. She showed significant clinical improvement 2 months after initiating the treatment. Currently, she is in the sixth month of her anti-TB regimen and continues to have follow-up appointments at the institution. A follow-up MRI (Fig. 3) revealed a round-shaped pancreatic lesion at the pancreatic junction of body and tail with peripancreatic and para-aortic lymph nodes.

Figure 3.

Abdominal MRI with contrast: (A and B) axial and (C) coronal T2, (D) post-contrast T1Fat Saturation (FS) (E and F) diffusion-weighted imaging and Apparent Diffusion Coefficient (ADC). There is a 2 × 1.7 cm measuring T2 intermediately hyperintense, relatively round-shaped restricting lesion having peripheral homogeneous enhancement with non-enhancing central foci at the junction of body and tail of the pancreas, indicated by an arrow. (F) Few restricting peripancreatic and para-aortic lymph nodes.

Discussion

Pancreatic tuberculosis was initially reported by Auerbach in 1944^[9]. Although abdominal TB is relatively common, pancreatic involvement remains a rare occurrence. The majority of the medical literature concerning this rare condition has been restricted to case reports or small case series. Primary pancreatic TB primarily affects immunocompromised patients and individuals living in TB-endemic regions^[5].

Possible mechanisms of spread include hematogenous dissemination from pulmonary or abdominal foci, direct extension from adjacent lymph nodes, or reactivation of latent bacilli in the setting of immunosuppression^[4].

Pancreatic TB can present with a wide range of clinical symptoms, often mimicking other conditions. The most commonly reported symptoms include epigastric pain (64%), fever (53%), weight loss (40%), and anorexia (36%)^[10]. Depending on the site and extent of involvement, patients may also experience jaundice, early satiety, abdominal pain, dyspepsia, gastrointestinal bleeding, pancreatitis, or even diabetes mellitus^[11].

In this case, the patient presented with significant weight loss, loss of appetite, and periumbilical colicky pain. Physical examination was largely unremarkable, except for epigastric tenderness and signs of emaciation. The nonspecific symptoms of pancreatic TB can easily be mistaken for those of pancreatic neoplasms or other granulomatous diseases^[12], as was initially suspected in the patient based on early imaging findings.

Diagnosing pancreatic TB is often challenging. Initial imaging modalities typically include abdominal ultrasound and CT scan. In the majority of instances, imaging for pancreatic tuberculosis shows a pancreatic mass in 79.5% of cases, with the mass most commonly found in the pancreatic head (59%)^[10]. Ultrasonography typically shows focal hypoechoic or cystic lesions^[13], while CT scans may reveal diffuse pancreatic enlargement, peripancreatic lymphadenopathy, or hypodense lesions with irregular borders, most often in the pancreatic head^[8]. A definitive diagnosis requires histopathological confirmation via biopsy, along with Ziehl–Neelsen staining, culture, and polymerase chain reaction (PCR) testing. The presence of caseating granulomas and acid-fast bacilli is highly suggestive of TB^[1,10].

In this case, abdominal ultrasonography revealed a hypoechoic lesion in the pancreatic tail, initially raising suspicion of a pancreatic neoplasm. An abdominopelvic CT scan subsequently revealed a septated cystic mass in the pancreatic tail, along with multiple enlarged lymph nodes in the mesenteric and retroperitoneal regions. Ultrasound-guided fine needle aspiration cytology (FNAC) of the pancreatic tail demonstrated well-formed granulomas and multinucleated giant cells within a necrotic background, findings consistent with pancreatic tuberculosis. Isolated involvement of the pancreatic tail is sporadic and distinguishes this case from the majority of those previously reported.

Management of pancreatic TB is primarily medical and offers a high likelihood of cure. Both pulmonary and extrapulmonary forms of TB are treated using the same antitubercular regimen. Standard therapy consists of a combination of isoniazid, rifampicin, pyrazinamide, and ethambutol for the initial 2 to 4 months, followed by isoniazid and rifampicin for an additional 4 to 8 months, for a total duration of 6 to 12 months^[5,11]. In cases complicated by biliary obstruction, endoscopic or surgical intervention may be necessary, as strictures can persist despite adequate medical therapy^[14].

The patient was treated with a standard anti-tubercular regimen consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol for the first 2 months, followed by rifampicin and isoniazid for an additional 4 months. She showed significant symptomatic improvement within the first month of treatment and is currently in the sixth month of follow-up at our facility.

To further contextualize the findings, we reviewed the literature and identified three similar cases involving immunocompetent patients who presented with comparable symptoms. Imaging studies in those cases also revealed pancreatic masses, later confirmed histologically as tuberculosis^[5,14]. However, all three cases involved the pancreatic body, whereas this case uniquely involved the pancreatic tail. To the best of our knowledge, this anatomical presentation is exceptionally rare and underscores the clinical significance of our report.

Conclusion

The diagnosis of pancreatic TB is still quite challenging, especially when the disease’s radiological and clinical manifestations closely resemble malignancy. This instance highlights the importance of histopathological analysis in differentiating TB granulomas from cancerous growths, thereby preventing unnecessary surgery and directing the appropriate course of treatment.

This case highlights the importance of healthcare workers to consider pancreatic tuberculosis as a differential diagnosis in instances of mass-forming pancreatic lesions, especially in regions where tuberculosis is endemic. Increased awareness among clinicians, radiologists, and pathologists is crucial for facilitating timely diagnosis and treatment. Implementing standardized diagnostic algorithms that incorporate advanced molecular and microbiological techniques could be beneficial for future research.

Ethical approval

Ethical approval was deemed unnecessary by the Institutional Review Board, as this is a single, rare case encountered during clinical practice and does not involve experiments on humans or animals.

Consent

Written informed consent was obtained from the patient for publication of this case report and use of images. A copy of the written consent is available for review by the Editor-in-Chief upon request.

Sources of funding

No funding was received for this manuscript.

Author contributions

The corresponding author managed patient care, collected data, drafted the manuscript, and coordinated revisions. All authors reviewed and approved the final version.

Conflicts of interest disclosure

The authors declare that they have no conflict of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Ayto A. Negash. The corresponding author serves as the guarantor for this article and takes responsibility for the integrity of the work.